Eyes/Ears

aqueous humor
made by the ciliary body; drains to maintain a relatively constant IOP and provides nutrients and oxygen to the cornea and lens
vision assessment
snellen chart and rosenbaum chart; assesses distant and near vision
visual fields assessment
standing right in front of the patient and moving your fingers in every direction-making sure the patient sees when you see; assesses peripheral vision
tests that assess eye movement
cardinal fields of gaze; cover test; corneal light reflex; and convergence
how to assess cardinal fields
used to evaluate extraocular eye movements; follow a pen through the six visual fields
cover test
used to evaluate alignment of the eyes; have the patient focus on an object and cover/ uncover the eye while noting any movement
how to assess corneal light reflex
shine a direct light source onto the bridge of the nose and observe for symmetric reflection of light
how to assess convergence
ask patient to follow penlight as you move it toward the patient’s eyes
tests that assess the pupils
observe size, shape, and equality; assess direct and consensual pupil response; and test for accommodation
how to assess direct and consensual pupil response
ask the patient to look straight ahead and shine a light obliquely into one eye at a time
how to test for accommodation
same as testing for convergence
parts of the external eye
eyelids, puncta, conjunctiva, sclera, cornea, and iris
how to assess the external eye
inspect the external structures and assess corneal reflex
how to assess corneal reflex
touch a light wisp of cotton to the cornea and it should blink and water
parts of the internal eye
lens and vitreous body, retina, optic disc, and macula
how to assess the internal eye
assess the internal structures with an opthalmascope
inspecting the lens and vitreous body
lens should be clear
inspecting the retina
there should be no visible white patches
inspecting the optic disc
round to oval in shape with clear, well defined borders
inspecting the blood vessels of the retina
retinal blood vessels should be distinct
inspecting the retinal background
retina should be consistent red-orange color, becoming lighter around the optic disc
inspecting the macula
should be visible on the temporal side of the optic disc
change to the lids with aging
raised, soft yellow plaques called xanthelasma on lids
changes to the cornea with age
lipid deposits around the periphery
changes to the pupil size with age
decreased pupil size and responsiveness to light
chalazion
a noninfectious cyst that develops on the eyelid
cause of a chalazion
chronic inflammation that is caused by obstruction of the sebacious gland; is painless and may go away without treatment
indication of a lid lesion that ulcerates/ does not heal
basal or squamous cell carcinoma; needs further investigation
Stye (hordeolum)
a pus filled cyst that is caused by inflammation and/or infection of the sebacious glands; internal or external
manifestations of external stye
visible, small raised area; photophobia, tearing, and sensation of foreign body in the eye
manifestations of internal stye
seen on the conjunctival side of the lid with more severe sx
marginal blepharitis
dandruff that attaches to the bottom of the eyelashes with mucoid drainage; normally caused by staph infection or dandruff of the scalp/ eyebrows
manifestations of blepharitis
irritation; lid margins may ulcerate resulting in loss of eyelashes
entropion
turning in of the eyelashes d/t inflammation of the eyelid causing pain and scratching of the conjunctiva or cornea and decreased acuity
ectropion
drooping of the eyelid causing the eye not being completely covered and damage to the cornea/conjunctiva
causes of ectropion
bells palsy, old age, nerve paralysis
nursing care of eyelid and eyelashes
need to know the source of irritation; cleansing and meds; and patient education; local heat applications
how to cleanse the eye
from the inner canthus and outward; wash eye with baby shampoo (no tears)
patient education of eye infections
explain how these things occur; hand hygiene; throwing away old makeup once you have the infection
conjunctivitis
inflammatory process of the conjunctiva (trauma, injury, infection)
adenovirus
the most common viral cause of conjunctivitis
“pink eye”
bacterial conjunctivitis that is very contagious and causes itchiness, drainage, photophobia, and increased tearing
dx of conjunctivitis
C&S; Fluorescein stain; and conjunctival scrapings
fluorescein stain
identifies possible corneal ulcerations or abrasions which appear green with staining
trachoma
conjunctivitis caused by chlamydia; heavy drainage in the acute phase and bumpiness on the eyelid causing scarring of conjunctiva and of the cornea
what meds are given for bacterial conjunctivitis
erythromicin eyedrops or ointment
meds for adenovirus
supportive type therapy such as steroid drops or warm compresses
meds for conjunctivitis d/t herpes simplex
antiviral meds (zovirax ointment)
meds for allergic conjunctivitis
antihistamines; eyedrops for comfort
comfort measures for conjunctivitis
frequent eye irrigations to remove discharge and soking the lids with warm saline compresses prior to cleaning
priority dx for conjunctivitis
risk for infection
risk for infections interventions
hand hygiene before instilling eyecare; deliver meds safely; avoid contact lenses until infection is cleared
impaired vision interventions
address perception for patient; educate on how to avoid activities that require high visual acuity; avoid injury
what precautions should be used when caring for the eye?
safety and medical asepsis; avoid excessive reading while eye is inflamed
cornea
clear covering in front of the eye that covers the pupil; light passes through the cornea and determines visual acuity
corneal ulcers
medical emergencies; pressure dressings may be applied to both eyes for comfort and to reduce the risk of perforation/ loss of eye contents
diagnosis for disorders of the cornea
visual acuity tests; fluorescein stain; and conjunctival scrapings
eye surgery for the cornea
corrects refraction of light; lasix surgery; corneal transplant
lasix surgery
reshapes the cornea
normal effects of lasix surgery
temporary loss of contrast sharpness; over/under correction of visual acuity; dry eyes; and temporarily decreased night vision
corneal transplant
can be recovered from cadavers; corticosteroids and antibiotics are given to reduce inflammation and infection
why is there a low rejection rate for corneal transplants?
there is no vasculature to the eye
signs of rejection
occurs within 3 weeks of the transplant; beginning with inflammation at the edge of the grafted tissue and spreading to involve the entire graft; treated with corticosteroid therapy
pre-op for eye surgery
patient education; assess visual acuity of both eyes and IOP; recognize what types of eyedrops will be used; prevent injury
how to prevent post-op eye injury
no straining, heavy lifting (no more than 5 lbs); no sleeping with head down or bending at the waist; eyepatches may cause further injury
mydriatic eye drops
dilate the pupil
cycloplegic eyedrops
immobilize the eye
post-op for eye surgery
reinforce patient education; decrease IOP; elevate HOB; and turn them to unaffected side; analgesic eyedrops are usually first choice
nursing dx for eye surgery
acute pain, impaired vision, and risk for injury
how to avoid increasing IOP
avoid straining (pooping and vomiting-administer laxatives and antiemetics); coughing, sneezing, bending over, and lifting heavy object
signs of corneal perforation
sudden, severe eye pain and photophobia
priority for corneal perforation
place the patient in supine position, close the eye, and cover it with a dry, sterile dressing; notify the physician immediately
priority for eye trauma
vision is evaluated, unless it is a chemical burn; do not assess eye movement if it is a penetrating object
priority for a chemical eye burn
*flush the eye immediately* with copious amounts of normal saline/ water to decrease trauma and then give IV analgesics
normal pH of the eye
7.2-7.4
diagnostics for penetrating object in the eye
MRI or CATSCAN
removal of a penetrating object
loose foreign objects may be removed using a sterile moistened cotton tipped applicator; *never* remove foreign objects that are embedded
nursing diagnosis for eye trauma
impaired tissue integrity: ocular
interventions for impaired tissue integrity: ocular
*preserve vision*; put a patch over the unaffected eye to keep the affected eye from moving
cataracts
significantly interferes with light transmission to the retina and the ability to perceive images clearly; works from inner eye to center
causes of cataracts
Congenital
*Aging*
Toxicity (steroids)
Accidents
Radiation (sunlight)
Altered metabolism (diabetes)
Cigarette smoking
diagnosis of cataracts
absence of red reflex with opthalmascope
surgery for cataracts
surgeon removes the lens and leaves the posterior capsule; the artificial lens is placed in the posterior lense
nursing diagnosis for cataracts
decisional conflict: cataract removal and readiness for enhanced self-health mgmt
normal IOP and flow
balanced by aqueous humor and flows through the pupil from posterior to anterior eye and is absorbed through the trabecular meshwork and Canal of Schlemm at the angle
manifestations of simple or chronic glaucoma
no initial manifestations; painless gradual loss of visual field
cause of simple glaucoma
the flow of aqueous humor through the trabecular meshwork and into the canal of schlemm is obstructed (cause unknown); pressure increases bc of the flow obstruction resulting in ischemia and damage to the optic nerve leading to gradual loss of vision
manifestations of acute angle closure glaucoma
flattened angle b/n iris and cornea causing rapid and severe eye/face pain; abrupt decrease in visual acuity
effects of dilation on angle closure in glaucoma
the iris thickens which causes the angle to close completely resulting in blocking of outflow of aqueous humor through the canal of schlemm causing an increase in the IOP
effects of increase in IOP in angle closure in glaucoma
damages the neurons of the retina and the optic nerve leading to rapid and permanent loss of vision
what can cause episodes of dilation
darkness and emotional upset
tonometry
indirectly measures the IOP
fundoscopy
visual inspection of the optic fundus using an opthalmascope
goinoscopy
measures the depth of the anterior chamber; differentiates between open angle and closed angle glaucoma
trabeculectomy
increases the angle to allow more drainage from the intraocular space
drug of choice for treating chronic glaucoma
prostaglandin analogs (Xalatin)
prostaglandin analog agents
-prost
action and side effects of prostaglandin analogs
increase aqueous outflow; may cause conjunctival hyperemia and changes in the color of the iris and eyebrows
action of beta blockers as related to the eyes
decrease the production of aqueous humor
adrenergic agonists (mydriatics)
-idine; dilate the pupil and reduces IOP for open angle glaucoma; *contraindicated in closed angle glaucoma*
nursing responsibilities for mydriatics
avoid OTC sinus and cold meds containing pseudoephedrine and phenylephrine; may accentuate the side effects
carbonic anhydrase inhibitor agents: action and side effects
-amide; decreases production of aqueous humor and IOP; has diuretic and hypotensive effects
nursing diagnosis for glaucoma
impaired vision; risk for injury; and anxiety
macula
area on the retina responsible for detailed central vision
fovea
the center of the macula and contains the rods and cones
macular degeneration
accumulation of deposits or leaking of blood vessels in levels of the retina resulting in decreased *central vision*; small areas of the pigmented layer of the retina become detached in the macular area causing distorting in central vision
manifestations of macular degeneration
blurred/distorted *central vision*; intact peripheral vision; problems with activities that require close central vision (reading, sewing, etc)
amsler grid
used to diagnosis AMD; lines in the center of the grid will look wavy
treatment for dry AMD
omega fatty acid, lutein, vitamin E and C, zinc, copper, and beta carotene
treatment of wet AMD
laser surgery photocoagulation
causes of retinal detachment
injury, shrinkage of the vitreous humor gel from age or myopia; glaucoma and cataract surgery increase risk, but it can happen spontaneously
manifestations of retinal detachment
sudden, painless, rapid loss of vision; sensation of a curtain or veil being drawn across vision; medical emergency
what does the patient experience when the retina detaches
floaters, cobwebs, flashes of light, rapid and progressive deterioration of vision; if the macula is involved, loss of central vision
interventions for retinal detachment
aimed at bringing the retina and the choroid back into contact which will reestablish blood supply and preserve vision
cryotherapy and laser photocoagulation
seals retinal holes, creates an area of inflammation and adhesion to bring the retina to the choroid
scleral buckling and pneumatic retinopexy
procedures that bring the retina to the choroid either through an injection or surgical intervention
nursing diagnosis for retinal detachment
*ineffective tissue perfusion: retinal* and anxiety
important interventions for ineffective tissue perfusion: retinal
position so the area of detachment is inferior, which places pressure on the detached area
enucleation blindness
removal of the eyeball from the orbit; able to wear a prothesis 1-2 months after surgery; monitor for signs of IOP
causes of otitis externa
removal of earwax; pseudomonas aeruginosa; injury/inflammation
manifestations of otitis externa
*ear pain that increases with manipulation of the auricle*; fullness in the ear; red, inflamed ear canal; and odorless drainage
nursing diagnosis for otitis externa
impaired tissue integrity
recommended treatment for otitis externa
thorough cleansing of the ear; local or systemic antibiotics; analgesics to relieve pain and itching; and educate to prevent recurrence
manifestations of ear impaction
feeling of fullness and tinnitus/coughing d/t stimulation of the vagus nerve
how to remove an insect from the ear canal
may try to be coaxed out with a flashlight or humming noise; mineral oil or alcohol is instilled to suffocate the insect, which is then removed with the use of special ear forceps
how to remove impacted cerumen
it is irrigated with water or saline by a professional to prevent trauma to tympanic membrane; mineral oil can be used to soften it
pathophysiology of serous otitis media
negative pressure in the middle ear causes fluid to be pulled from the capillaries into the middle ear; the negative pressure causes the retracted tympanic membrane and the fluid build up causes the look of bubbles
manifestations of otitis media
pain is *not* increased with manipulation of the ear, conductive hearing loss, and pain
pathophysiology and manifestations of acute otitis media
usually follows an upper respiratory infection; causes eardrum to look swollen, bulging, red, and inflamed
treatment of serous otitis media
should spontaneously resolve within 2-4 weeks; may use anti-inflammatory or anti-histamines; perform Valsalva’s Maneuver
treatment of acute otitis media
antibiotics (Amoxicillin 5-10 days), anti-histamines, and analgesics
nursing dx of acute otitis media
acute pain
myringotomy
a temporary ear tube is inserted to drain fluid from the otitis media; used when antibiotics are ineffective, to relieve excess pressure and to prevent rupture of the eardrum
pre-op for myringotomy
assess hearing and establish communication; do not blow nose, cough, or sneeze; keep mouth open as much as possible
post op for myringotomy
assess v/s, drainage from ear, hearing, vertigo, nausea, and pain; *elevate HOB*, place on unaffected side; anti-emetics
home care for myringotomy
infection control measures; antiemetics and antihistamines
mastoiditis
usually occurs 2-3 weeks after untreated or ineffective treatment of otitis media; pain with minimal movement of the head and systemic signs of infection
otosclerosis
a stiffening or over growth of the bones of the middle ear leading to conductive hearing loss
diagnostics for otosclerosis
reddish or pinkish-orange tympanic membrane; Rinne test will show bone sound conduction to be equal or greater than air conduction
treatment of otosclerosis
hearing aids or stapedectomy
Meniere Syndrome
recurrent attacks of vertigo and a progressive unilateral hearing loss; has to do with increased pressure in the ear d/t increased fluid
electronystegmography
identifies eye movement in response to changes in head position or instillation of water; contrindicated in perforated tympanic membrane
glycerol test
gives the patient oral glycerol to decrease fluid pressure; improvement in hearing is positive for Meniere’s disease
medication for menieres disease
antiemetics, anticholinergics, diuretics, and vasodilators
measures to avoid vertigo attacks
avoid salt, monosodium glutamate, caffeine, sugar, and alcohol; refrain from smoking
measures to help vertigo attacks
restrict the client to bed rest in a quiet/dark environment; instruct client to move the head slowly to prevent worsening of the vertigo
nursing dx for inner ear disorders
risk for trauma and disturbed sleep pattern
pure tone audiometry
used to identify problems with hearing, speech, music, and other sounds in the environment
speech audiometry
the clients ability to hear spoken word is measured; after testing, audiogram patterns are depicted on a graph to determine the type and level of hearing loss
nursing responsibility during audiometry
instruct client to identify sounds as they are heard during the test
presbycusis
degeneration of the hair cells of the cochlea d/t aging which causes sensorineural hearing loss; hearing aid is usually prescribed
Hearing aids
more effective for clients with conductive hearing loss; hearing aids may amplify background noise in addition to voices which may cause problems for some clients
nursing diagnosis for hearing impairement
impaired hearing, impaired verbal communication, and social isolation

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